心包疾病pericardial disease 中山大学 内科学课件

Pericardial Disease Wutao Zeng Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University General characteristics (Normal Pericardial Anatomy and Physiology) 1.Pericardium is the membranous sac surrounding the heart. 2. The pericardium consists of two layers: visceral layer and parietal layer. 3.There is about 50ml pericardial fluid in the pericardial cavity. The normal functions of the pericardium lMaintaining an optimal cardiac shape. lReducing friction between the beating heart and adjacent structures. lProtecting the heart from other diseases which are caused by the neighboring organs: inflammation , TB, cancer etc. lPreventing the overfilling of the heart. Classification of Pericardial Diseases lCongenital defect lPericarditis lacute pericarditis lpericardial effusion l constrictive pericaditis. lPericardial neoplasm lPericardial cysts Acute pericarditis Definition Acute pericarditis is an inflammation of the pericardium. Etiology The disease may be idiopathic or secondary to other diseases, for example Viral infection: coxsackievirus B, CMV Bacterial infection: Staphylococcus sp, Streptococcus sp, tubercle bacillus Post-MI complications Drugs Malignancy Collagen vascular disease Pathology lEarly stage： fibrous protein pericarditis lProgressive stage： Rapid effusive pericarditis acute cardiac tamponade Chronic accumulation is accommodated by the expanding pericardium myopericarditis lFinal result： The exudate was completely dissolved and absorbed Organization calcification of pericardium constrictive pericarditis pathophysiology Acute pericardial effusion The pressure of the pericardial cavity FV( filling volume) of the ventricular diastole SV( stroke-volume) BP Clinical Manifestations -fibrous protein pericarditis Chest pain (Symptoms) lPosition ： lretrosternal or precordium, midsection lCharacter： lsharp pain, dull pain, compression lWorsen ldeep breathing, cough, and lying down. lRelieved lsitting and leaning forward. Pericardial friction rub (Signs) lBoth systole and diastole lThis finding is diagnostic Clinical Manifestations -Pericardial effusion Symptoms lDispnea lPressure symptoms： ldry cough(bronchus) l hoarseness(laryngeal nerve) l dysphagia（ esophagus) Signs lphysical sign of the heart ltachycardia, indistinct heart sounds lEwart sign (consolidation of lower lobe of left lung) lHypotension lSBP，pulse pressure leven paradoxical pulse. lCongestion of systemic circulation ldistended jugular vein ledema Clinical Manifestations -Cardiac tamponade lAcute ：Becks trilogy lHypotension or shock lDistended jugular vein lIndistinct heart sounds lSubacute or chronic： l venous pressure lcongestion of systemic circulation lKussmaul sign( dilation of jugular vein during inspiration) Laboratory findings - ECG lStage I:ST segment elevation (concave upward not convex) in all leads except avR and V1 without reciprocal ST segment depression (which occurs in MI) (Several hours later). lStage II: ST segments return to baseline, the initially upright T waves flatten (several days later) lStage III:T waves invert (weeks later) lStage IV:T waves revert to normal (weeks or months later) Other changes: Large effusion can cause both reduced voltage and electrical alternans. EKG of Acute pericarditis (Stage I) Acute inferior myocardial infarction Laboratory findings - Chest x-ray film lCardiac shadow has an enlarged “water- bottle” appearance. lClear lung field. lCardiac shadow changes with postures. Laboratory findings -Echocardiography This is the best noninvasive investigation for confirming diagnosis of a pericardial effusion Laboratory findings - Pericardiocentesis 1.Pericardiocentesis can help to make diagnosis. Fluid should be sent for culture and assay lProtein, glucose and LDH assays: LDH, glucose and protein determine if fluid is a transudate or exudate; lCytology and tumor marker: CEA, AFP, CA125 and so on; l ANA assay: if collagen vascular disease is suspected. 2. Pericardiocentesis can relieve the pressure of pericardial cavity. Diagnosis of Acute Pericarditis lChest pain aggravated by coughing, inspiration,or recumbency lPericardial friction rub on auscultation lCharateristic EKG changes lChest X-ray and UCG may find pericardial effusion Differential Diagnosis of Acute Pericarditis Acute idiopathic pericarditis Tuberculous pericarditis Purulent pericarditis Maligancy Postpericar diostomy syndrome Histrory History of up respiratory tract infection ，acute onset，often recurrent Accompanied with primary TB Accompa nied with original infection lesion or septemia Frequently caused by metastatic tumour History of cardiac injury such as operation, myocardial infarction, may often recurrent FeverConstant fever seldom High fever seldomoften Pericardi al friction rub obviously， occur early oftenoftenseldomseldom Chest pain Often severely seldomoftenseldomoften Acute idiopathic pericarditis Tuberculous pericarditis Purulent pericarditis Maligancy Postpericardi ostomy syndrome Leukocyte count Normal or increase Normal or slightly increase Significantl y increase Normal or slightly increase Normal or slightly increase Blood culture + Volume of pericardial effusion LittleLargeLargeLarge Medium Characteris tic Grass yellow or hematic Often hematic Purulent Often hematic Often serosity Differential Diagnosis of Acute Pericarditis Differential Diagnosis of Acute Pericarditis Acute idiopathic pericarditis Tuberculous pericarditis Purulent pericard itis Maliga ncy Postperica rdiostomy syndrome Classificati on of leukocyte More lymphocyte More lymphocyte More neutrophil More lymphocyte More lymphocyte BacteriaNone Tubercle bacillus may be found Purulent bacteria NoneNone TreatmentNSAIDs Anti-tubercle bacillus Antibiotic or pericardi otomy Treat original diseases, Perecardio centesis Steroid Treatment l1.Etiology treatment lBacterial infection lViral infection lTB lMalignancy lCollagen vascular disease l2. Relieving pain and inflammation: lNSAIDs and steroids l3.If symptoms are severe, pericardiocentesis is indicated to remove fluid. Constrictive pericarditis Definition Constrictive pericarditis is a thickening and fibrosis of the pericardium that occurs long after an acute episode of pericarditis. It produces decreased diastolic filling. Etiology lTB is a leading cause in underdeveloped countries including China, about 40%. lOthers: Purulent inflammation, Pericardial injury, Radiation therapy etc. Clinical Manifestations Symptoms: lDyspnea on exertion and orthopnea lOther symptoms lHypodynamia lBig belly Physical Signs: lDistended jugular vein lKussmaul sign lEdema, ascites lHeart sounds are distant and a pericardial knock is detected after S2 lS